Provider Demographics
NPI:1225156581
Name:GONZALES, GENEVA
Entity Type:Individual
Prefix:
First Name:GENEVA
Middle Name:
Last Name:GONZALES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3024 CESAR CHAVEZ DR
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-5104
Mailing Address - Country:US
Mailing Address - Phone:505-763-3323
Mailing Address - Fax:505-769-8974
Practice Address - Street 1:1100 W 21ST ST
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-4151
Practice Address - Country:US
Practice Address - Phone:505-763-3323
Practice Address - Fax:505-769-8974
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator